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The ED Physical Environment: Preparing for Behavioral Health Patients

In recent weeks (months?!), there’s been a lot of discussion relative to the identification and mitigation of risks in the environment relating to the management of behavioral health patients. At least for the moment, the “pressure points” from a regulatory perspective seem to be sorting out into three care environments – behavioral health inpatient units, acute care inpatient units, and emergency departments.

In any number of ways, the ED is the most challenging environment because it is so difficult to designate rooms for specific purposes (other than trauma rooms – usually everyone has at least one of those), including at-risk patient populations, particularly behavioral health. And you not only have to be able to provide a safe physical environment for those at-risk patients, your front-line staff has to be able to articulate the measures that might be put in place to minimize risks, as well as to identify the strategies for managing any risks that remain once the environment is “safed” to the extent possible/reasonable.

The “trick” to all of this is that it is nigh on impossible to predict when these at-risk patients are going to show up at your door, so your process framework has to be spot on every moment of every shift. And that includes education of any and all staff that might provide care to / interact with these patients. The important thing to remember is that, for all intents and purposes, these patients are going to be “at risk” pretty much the whole time they’re in your ED.

It all comes down to a comprehensive risk assessment of the physical environment – keeping in mind the importance of identifying “all” the risks in the space; the focus of the moment is ligature risks, but ligatures are not the only way that patients can harm themselves or others. Once you’ve identified the risks, you can then work to eliminate some of the risks (you’ll never get rid of all of them), and then develop strategies for managing whatever risks remain. At this point, it mostly comes down to monitoring and effective interactions with the patient(s) including de-escalation and response if things threaten to “boil over”.

One of the key processes to have in place is the establishment of a behavioral emergency response team (BERT) that is intimately familiar with the continuum of safe care for these patients, including mitigation strategies, de-escalation techniques, etc. While it is of critical importance for each staff member providing care, treatment, or services to these patients to be active participants in the process and, so, appropriately educated, it is equally important to have a well-prepared response process to support the folks in the ED.